GPs, THE NTA AND THE NUMBERS GAME

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In good faith, the Substance Misuse Management in General Practice issued guidance now proven to be based on unfounded figures – they were taken at face value from the National Treatment Agency for Substance Misuse. Peter O’Loughlin puts the record straight.

Many – perhaps most of us – have become accustomed, even weary, of the plethora of self-congratulatory announcements issued by the National Treatment Agency for Substance Misuse. Most of the spin aims to persuade us that protocols and implementations of the current drug treatment strategy are succcessful. Indeed, such is the glutof these proclamationsof success, that there is a temptation, at least by this writer, to skip them in favour of more factual and unbiased reading.

On the other hand, when a responsible and professional network such as the Substance Misuse Management In General Practice chooses to re-issue verbatim one of the more misleading documents emanating from the NTA, and endorse it as an “important report”, this writer sits up and pays attention.

The document in question is Good Practice in Harm Reduction (NTA report, October 2008).

While acknowledging that government targets for reducing drug-related deaths have not been met, it makes the following claim: “Drug related deaths have gone down in recent years”.

It then purports to show how harm reduction “combines work aimed directly at reducing the number of drug-related deaths and blood-borne virus infections, with wider goals of preventing drug misuse and of encouraging stabilisation in treatment and support for abstinence”.

It is the intention of this article, with the aid of statistical evidence from the Office of National Statistics and the Health Protection Agency, to show that the claim relating to drug deaths is palpably misleading – and that the current emphasis on harm reduction is failing not only in reducing drug deaths, but that they are actually increasing. This is alongside the abysmal failure of inappropriately named “harm reduction” methods to contain the escalation of blood-borne diseases.

OFFICE OF NATIONAL STATISTICS' FIGURES.

The following facts for drug deaths arising from misuse were published by the ONS in its April 2007 and autumn 2008 reports.

Drug deaths from heroin and morphine are increasing year on year

In 2003-4 there was a marked increase in drug-related deaths which were largely attributed to heroin, methadone and morphine.

Drug-related deaths are the highest in five years.

The total number of drug-poisoning deaths arising from drug misuse in 2007 increased by 16% from 2006, to 2,640.

In 2007, 196 deaths involving cocaine occurred, the highest number of deaths involving cocaine since records by the Office of National Statistics began in 1993.

Deaths attributed to methadone are at their highest since 1999. In 2007, methadone-related deaths increased by 35% over 2006 to 325.

The level of HIV infection among injecting drug users (IDUs) in England and Wales is higher now than at the start of the decade.

In London, where the prevalence of HIV in IDUs is higher than elsewhere in England and Wales, one in 20 IDUs is infected.

In the remainder of England and Wales, HIV among IDUs has risen from about one in 400 in 2002 to about one in 150 in 2006.

The prevalence of hepatitis C among IDUs has risen from 33% in 2000 to 42% in 2006.

About one in five IDUs has hepatitis B infection, which extrapolates as an increase approaching 200% since 1997.

FACING THE FACTS.

It is self evident from the facts that the disproportionate emphasis on harm reduction is failing to achieve that which the NTA document would have us believe.

The author(s) of the document contents have – knowingly or unknowingly – resorted to a technique known as ‘perception management’. This process could be regarded as more sinister than spin, since it seeks to bury the truth under a garbage of rhetoric in order to manufacture a ‘truth’ designed to influence or change the perceptions of a targeted audience.

Via email, I expressed my disappointment to the SMMGP for publishing as a “policy update” the NTA document, together with the endorsement the SMMGP gave. I now place on record my appreciation to Dr Chris Ford for the courtesy and promptness of her response.

In an age where avoidance of responsibility is so common, I also take this opportunity of expressing my admiration and respect for the forthrightness of her “mea culpa”, together with the integrity and that rare quality of humility which she displayed in our subsequent correspondence.

PETER O’LOUGHLINis certificated in substance misuse and dependency by the Department of Addictive Behaviours, St George’s Medical School and Addaction, is an associate member of the Medical Council on Alcohol, a registered psychotherapist and clinical hypnotherapist. His 25 years’ experience spans detox, street work, rehabilitation,1:1 and group counselling.

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This was the NTA response to Peter O’Loughlin’s original complaint to the SMMGP “Your correspondent may be confusing the timing and purpose of different reports. Good Practice in Harm Reduction was written before the autumn 2008 ONS figures were released and was intended to highlight common themes of good practice in partnerships that performed well in the NTA/Healthcare Commission review of harm reduction in 2006-7. We share his concern that drug-related deaths are high and rose in 2007. Since 2007 the NTA has been working on the Department of Health action plan to reduce drug-related harm. This plan, set out in the document Reducing Drug-Related Harm: An Action Plan, includes government action on campaigns, improving delivery and surveillance. More specifically, the NTA has made available a range of harm reduction materials as part of the Harm Reduction Works campaign, will be issuing updated guidance on local confidential enquiries into drug-related deaths, and is about to run a pilot on providing naloxone to users and carers. While drug-related deaths are an important issue deserving of this greater attention, we do not think it is either “optimistic” or “misleading” to draw attention to examples of good practice from which other partnerships might learn and which, if copied, might help to prevent some drug-related deaths.” Tim Murray Policy Officer, National Treatment Agency for Substance Misuse

Readers may be interested to learn that the publication of this article was delayed pending a response from the NTA to the SMMPG. In the light of the nature of that response which has been posted on the SMMPG website, this writer saw no reason to make any amendements to his original submission.

Well done Peter for bringing to the attention of the SMMGP (and many others who will read your article) yet another incident of the NTA trying to spin statistics for their own benefit. When will something be done about this behemoth and the huge amount of money it is spending to promote ‘treatment’ – aka harm reduction ? The £14 million they spent last year – none of it on treament – would provide many places in residential rehab for users who desperately want to get clean. Is there nothing that can be done to close down the NTA and use the funds to support residential rehab and drug prevention services ?

THIS COMMENT FROM THE NTA WAS RECEIVED 23 FEBRUARY 2009. Addiction Today’s response is below it. ——- I have just tried to ring you. What do you mean by this strapline on the front page of your website, which appears to relate to p33 of the latest Addiction Today? Are you suggesting the NTA published unfounded figures? What is this proof you claim? Have you read Good Practice in Harm Reduction? What figures in there are “unfounded”? Your correspondent Peter O’Loughlin doesn’t like us using the phrase “although drug-related deaths have gone down in recent years” but that doesn’t mean SMMGP “issued guidance now proven to be based on unfounded figures.” ONS figures for drug-related deaths in England (Health Statistics Quarterly 39, published autumn 2008) gave the following totals for deaths related to drug misuse: 2003 1,313 2004 1,415 2005 1,506 2006 1,469 2007 1,479 You can see from this that the five-year peak to which Peter refers, cited by the NAO in its report, was in 2005. That was the benchmark figure which prompted the Government to launch its harm reduction Action Plan. Since then, the figures have gone down, as we pointed out. In fact Good Practice in Harm Reduction was published last October, before the ONS provided the 2007 figure, which showed a slight increase, but the current total is still below the 2005 peak. So, our point holds, and it is not strictly true to say any longer that “drug related deaths are the highest in five years.” Having said this, the numbers of drug-related deaths are still too high. We are trying to reduce them. That is why we published Good Practice in Harm Reduction, as on on-going part of delivering the Action Plan. As ever, happy to discuss. However, do think your strapline is seriously misleading and I would ask you to reflect on whether you should be making such an allegation. Jon Hibbs Director of Communications National Treatment Agency 8th Floor, Hercules House Hercules Road London SE1 7DU T – 0207 261 8775 F – 0207 261 8883 From 16 March 2009 NTA Headquarters will be at: 6th Floor, Skipton House, 80 London Road, London SE1 6LH.

ADDICTION TODAY REPLY TO JON HIBBS, NATIONAL TREATMENT AGENCY FOR SUBSTANCE MISUSE, February 2009 ——- Dear Jon, First, let’s answer your question: “Are you suggesting the NTA published unfounded figures? What is this proof you claim?” No – however, the following highlight considerable discrepancies between the figures contained in your email and those provided by The Office for National Statistics; Health Statistics Quarterly, published in August 2008, states the following: * “Male deaths from drug poising are at their highest for 5 years; * “There were 1,914 male deaths related to drug poising in England and Wales in 2007, which is the highest recorded number since 2002. this compares with 1,782 in 2006 and represents a rise of 7 percent; * “The total number of drug poisoning deaths in 2007 was 2,640, which included a 16 per cent rise in deaths involving heroin and morphine compared with 2006. There were 829 heroine and morphine related deaths in 2007 and 713 in 2006: * “The number of deaths involving methadone rose to 325, an increase of 35 per cent since 2006 and the highest level since 1999; * “There were 196 deaths involving cocaine in 2007, continuing a long term upward trend. this is the highest recorded number of deaths involving cocaine since the ONS database began in 1993.” Apart from the underlining which is added for ease of reference, the foregoing has been reproduced verbatim; for confirmation I refer you to Health Statistics Quarterly 39 autumn 2008 (p82) http://www.statistics.gov.uk/statbase/Product.asp?vink=6725 The figure from ONS (based on PM data) is consistent with the data from NP-SAD (based on coroner reporting); is available at http://www.intervene.org.uk/addictiontoday/2009/02/drug-deaths-uk-2008-npsad.html In the light of the foregoing, Peter O’Loughlin’s update – that the statement by the NTA that “drug related deaths have gone down in recent years” is “misleading” – is justified. However, since the figures you quote, which you seek to persuade me are from the same source, are considerably different, you might wish to check with the ONS and or your own organisation how the discrepancies arose – after all, the NTA has been given many millions of £££s of taxpayers’ money, including mine, to just that. Did you not take the opportunity to do so before contacting me? I am puzzled by your reference to “the five year peak to which Peter refers” because nothing in his article refers to “peak” or 2005. Also, your claim that “since then the figures have gone down”, is not substantiated by the report referred to above. How can we then take seriously your insistence in continuing to claim that “it is not strictly true to claim any longer that drug related deaths are at their highest for five years”. On the contrary, the figure published by the ONS in August 2008 pre dates your October report of the same year and clearly contradicts your claim that drug-related deaths have gone down. Earlier this month, The SMMPG reproduced a document published by the NTA dated October 2008 entitled Good Practice in Harm Reduction. In doing so it was offered as a ‘Policy Update’ and subsequently endorsed by the SMMPG as “an important document” – I therefore fail to see why you suggest that Addiction Today article strapline is misleading. We both agree that drug related deaths are far too high. You state that the NTA wishes to reduce them – but the NTA actions do not match the words. There might be improved awareness and measurement (eg around cocaine deaths), but we still have a situation where there is marked under-reporting: for instance, numerous deaths from endocarditis are not picked up as drug-related, and the definition used by ACMD omits all the chronic death causes. In addition, the switch to methadone means that people are less likely to have overdoses but are much more likely to have chronic deaths relating to things like tobacco or alcohol or general poor physical health and coping! What is the NTA doing to measure and map changes in chronic drug-related deaths: blood-borne viruses as well as tobacco- and alcohol-related deaths among long-term-treated populations? By “long term treated”, I mean people on the NTA methadone policy (rather than drug-free goals treatment) for years or decades, be it clinically appropriate or not. After almost eight years of taxpayer funding, treatment protocols are failing in not only reducing drug deaths but even in arresting them. Methadone deaths have risen. In the same time, referral of clients to residential, drug free rehabilitation – followed by competent and ongoing aftercare before the severity of addiction in any individual reaches a point of no return (death) – has fallen to 2%. I have not even touched on the lack of provision in NTA policy for the common co-occurring disorders, including mental disorders, associated with drug misuse, which in themselves are a trigger for relapse. However, in a spirit of cooperation, I am happy to give you desired publicity re Paul Hayes’ recent claim in the Independent that referrals to rehab have quadrupled suddenly to 8%, as soon as you supply me with independent audit of this claim. I am also happy to publicise your claims this week. Deirdre

Deirdre I am grateful for the trouble you have taken in responding, but with the greatest respect I fear I haven’t got my point across. My concern is with the headline on Peter’s article, which implied we gave material to the SMMGP “proven to be based on unfounded figures.” In fact there are hardly any figures quoted in the document Good Practice in Harm Reduction. What Peter has taken issue with is the claim that “drug-related deaths have gone down in recent years.” That claim is based on the drug-related deaths figures for England cited by the ONS in its report, Deaths Related to Drug Poisoning in England and Wales, 2003-7, published in Health Statistics Quarterly 39.http://www.statistics.gov.uk/downloads/theme_health/HSQ39.pdf This article starts on page 82 of the HSQ but the key bit for me is page 85, where there is a table (table 3) for numbers of deaths related to drug misuse. That is the source for the figures I gave in my email. You will notice the text box next door to table 3 explains the internationally-accepted ONS definition for drug-related deaths. You helpfully quote back at me highlights from the ONS bulletin on deaths from drug poisoning in August 2008. This trailed in advance the material in the HSQ report I just mentioned, Deaths Related to Drug Poisoning in England and Wales, 2003-7. I’m not disputing these figures, but they are deaths from drug poisoning. As the bulletin makes clear, deaths related to drug misuse/dependence is one subset of this total, alongside deaths from accidental poisonings and deaths from intentional self-poisoning/suicide. Table 3 makes this explicit when it says that drug misuse deaths are 61 per cent of all the deaths on the database. The fact that male deaths from drug poisoning are now at their highest for five years does not mean that drug-related deaths (ie deaths from drug misuse or dependency) are at their highest – in England, that point was back in 2005. So I would respectfully suggest the confusion between us is not a discrepancy that reflects badly on the NTA or the ONS, they are two different things. Peter is making his argument based on total figures for drug-related poisonings, which includes figures for deaths from heroin and methadone and cocaine, but covers accidents and suicides as well as deaths from overdose. The NTA’s concern is with this narrower category of drug-related deaths because reducing them was the benchmark we were set by the Department of Health when it launched the Harm Reduction Action Plan in 2007. At that point, drug-related deaths were rising. They have come down since, but not by enough – which is why the work continues, and why we published the Good Practice guide. The np-SAD report is about drug-related deaths in this narrower sense, but covers the UK so the figures are higher than the England-only figures I quoted (because the NTA has no jurisdiction outside England). The St George’s research is very useful, and we noted its conclusion that the proportion of overdose from methadone are up (from 17 per cent to 20 per cent). However, as acknowledged in the first bullet point of its release, the database is limited to what it receives from 107 out of 115 coroners. It is not therefore a comprehensive record of drug-related deaths, as it relies on individual coroners returning data. You make a number of other interesting points which explains why you don’t like what the NTA is doing (or not doing) but my concern is with the allegation that we issued guidance that was proven to be based on unfounded figures. That is not supported by the evidence you supply, possibly because of a fundamental misunderstanding by your correspondent between what is being counted as deaths from drug poisonings on the one hand and drug-related deaths on the other. Once again I tried to ring to discuss, but couldn’t get through. Jon Jon Hibbs Director of Communications National Treatment Agency 8th Floor, Hercules House Hercules Road London SE1 7DU T – 0207 261 8775 F – 0207 261 8883 From 16 March 2009 NTA Headquarters will be at: 6th Floor, Skipton House, 80 London Road, London SE1 6LH.http://www.nta.nhs.uk Effective treatment. Changing lives.

As the author of the article on drug related deaths, I am concerned that Jon’s response might serve to lose sight of the relevant facts, which are as follows… On August 28 last year, the ONS issued a news release, the headline of which is now reproduced verbatim: “Male drug poisoning deaths are at their highest in 5 Years” In paragraph 2 of that document, the following statement is made: “There were 1,914 male deaths related to drug poisoning in England and Wales in 2007, which is the highest recorded number since 2002. This compares with 1,782 deaths in 2006 and represents a rise of 7 per cent.” The first and relevant sentence in Paragraph 4 states: The total number of drug poisoning deaths in 2007 was 2,640 which included a 16 per cent rise in deaths involving heroin and morphine compared with 2006. The NTA document entitled ‘Good Practice in Harm Reduction’ dated October 2008, a little over two months after the ONS news release, made the following unqualified and stand alone claim: “Drug related deaths have gone down in recent years”. The NTA claim is – as stated in my article – “palpably misleading”. Given that Jon has made no attempt to dispute my statement, I could have equally and legitimately described the NTA claim as deceptive, ambiguous, confusing, false, disingenuous, or unfounded. Although Jon has chosen not to dispute my statement and is unable to dispute the statistical evidence, he has chosen to seek refuge in the sanctuary of semantics, with the ridiculous suggestion: to wit, that deaths arising from drug poisoning are not ‘drug related’. Readers will make their own judgement as to whether or not that esoteric proposition is valid. In view of the foregoing, I now ask Jon whether or not his dispute with the use of “unfounded” in Deirdre’s strapline is no more than a ‘red herring’? a desperate and futile attempt to divert attention not only from the regrettable and harsh truth of the increase in drug-related deaths, but also an equally desperate attempt to divert attention from what could be regarded as a cynical, opportunistic and deliberate ploy, by the NTA to advance its self serving interests with the insidious tool of ‘Perception Management’?

Jon’s point is relevant and not pedantic semantics. In the same way that in volatile substance abuse related deaths, it is sensible to separate the accidental deaths of users from the suicides of others. Both are tragic but would be addressed in different ways.

If, dear reader, you have got this far you will have heard the NTA case; and I have nothing to add to the rhetorical questions being posed except to note the trend increase in derogatory adjectives applied to the NTA when it seeks to engage in debate to defend its reputation.

I also can’t see how differentiating between suicides and accidental overdose is pedantic. Surely we are trying to count deaths due to drug dependency or misuse. People have always used drugs for suicide but this is a different issue.

Peter, I am afraid that what you call semantics is in fact the truth. Jon is correct in his defence of what the NTA quoted and should not be attacked by you for that. I read this article expecting a mature debate on what the figures are telling us only to read your biased and incorrect reading of both the figures and what public servants round the country are working hard to achive. Why is our profession so stuck in this pollarised debate between harm reduction and abstinence? Can we move on now please and concentrate on the strengths that we all bring to helping people change their lives?

In response to the comments posted by the NTA and others, I stand by my original statement that the NTA statement in respect of Drug Related Deaths is misleading; in doing so I would draw the NTA’s attention to the following. In 2000 the advisory Council on the Misuse of Drugs (ACMD) published a report, ‘Reducing Drug Related Deaths’ (1) that fed into the ten year strategy. In addition to several recommendations about the prevention of drug misuse deaths, the ACMD recommended that a better system for the surveillance of drug misuse deaths was needed. In response to this recommendation, a technical working group was set up consisting of experts across government, the devolved administrations, coroners, toxicologists and drug agencies. The working group reviewed the system for collecting data on drug related deaths and proposed an indicator for the surveillance of deaths related to drug misuse. “The definition of the indicator is, deaths where the underlying cause is poisoning, drug abuse or dependence and any of the substances controlled under the Misuse of Drug Act (1971) are involved”. The definition was accepted by the DoH (2) and still stands today, therefore not only is the NTA claim misleading, they have disregarded their own department’s acceptance of what constitutes drug related deaths. This is aggravated by subsequent attempts on this and other websites to further obfuscate the true extent of drug related deaths. In view of the foregoing I reject the subsequent NTA claim that my questions posted on this site are rhetorical – and submit that my questions are relevant and that the NTA has both a duty and obligation to respond to them. References: 1. Advisory Committee o the Misuse of Drugs (2000) Reducing Drug Related Deaths. The Stationery Office: London. 2. Department of Health (2001) The Government Response to the Advisory Council on the Misuse of Drugs Report into Drug Related Deaths, The Stationery Office London

If someone kills themselves, that is a suicide, not a drug related death. The new Scottish Database, which has just started, differntiates this point, after much debate. Whether the drug use was a contributory factor, when it comes down to it in a statistical sense, is irrelevant. If unsure, they are added as a drug related death. What I would like to ask is why we dont have so many opioid related deaths in hospitals as the diamorphine used there is at 100% purity. And then I would like to ask why are drugs not regulated and controlled to stop so many people dying! The debate should not be about abstinence or harm reduction, it should be about regulated supply as there will be a lot less people dying if this happens.

Thank you for you comment Noel. Whilst your opinion is interesting, it does not change the UK official definition of what a drug related death is, nor does it change the fact that the NTA has made a false claim in respect of those deaths. The latter is what this debate is about, not as you suggest abstinence v harm reduction. Whilst that may not be to your liking, if you feel a debate about regulation and control is necessary, you’re free to initiate it under a seperate blog.